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Multicenter Study
. 2003 Mar 29;326(7391):684.
doi: 10.1136/bmj.326.7391.684.

Ethnographic study of incidence and severity of intravenous drug errors

Katja Taxis  1 , Nick Barber
Affiliations
Multicenter Study

Ethnographic study of incidence and severity of intravenous drug errors

Katja Taxis et al. BMJ. .

Abstract

Objectives: To determine the incidence and clinical importance of errors in the preparation and administration of intravenous drugs and the stages of the process in which errors occur.

Design: Prospective ethnographic study using disguised observation.

Participants: Nurses who prepared and administered intravenous drugs.

Setting: 10 wards in a teaching and non-teaching hospital in the United Kingdom.

Main outcome measures: Number, type, and clinical importance of errors.

Results: 249 errors were identified. At least one error occurred in 212 out of 430 intravenous drug doses (49%, 95% confidence interval 45% to 54%). Three doses (1%) had potentially severe errors, 126 (29%) potentially moderate errors, and 83 (19%) potentially minor errors. Most errors occurred when giving bolus doses or making up drugs that required multiple step preparation.

Conclusions: The rate of intravenous drug errors was high. Although most errors would cause only short term adverse effects, a few could have been serious. A combination of reducing the amount of preparation on the ward, training, and technology to administer slow bolus doses would probably have the greatest effect on error rates.

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Figures

Figure
Figure
Stages and errors in preparation and administration of intravenous drugs (numbers of errors/number of observations of each stage)
See this image and copyright information in PMC

References

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